The Funding Barrier

Change

Small victories mean a lot and even small changes can be really powerful.

When an inmate is identified as HIV-positive the DOC is legally obligated to provide "medical care while incarcerated, counseling, and referrals to support services." However, the JHA memo states that "implementation [of the statute] relating to treatment is 'subject to appropriation,'" i.e., the legislature actually providing DOC with the funds necessary to fulfill the mandate. So unless the legislature comes up with that funding, there is no duty to implement the statute. There is also a financial disincentive for the DOC to test inmates upon entry rather than waiting to test them when they are nearing release, thereby avoiding the cost of treating them while they are in custody.

And so a vicious cycle of unknown HIV status, risky behavior that results in more infections, leading to more HIV-positive inmates being released without knowing of their infection, ending with ongoing new infections in the community is perpetuated.

With so many states in financial trouble, it seems likely that the same situation exists throughout the country and perhaps in federal prisons as well. And funding for Medicaid, community health centers, and HIV prevention is cut with no thought to the long-term consequences.

Telemedicine

But there is some good news, at least here in Illinois. A partnership of DOC with the University of Illinois Medical School is providing telemedicine monitoring of HIV-positive inmates, a program that Maki is enthusiastic about. Telemedicine allows for an HIV specialist to communicate by computer, via Skype or a similar service, with HIV-positive inmates, monitor their lab tests, and discuss any questions or concerns they may have about their drug regimen.

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"It's getting rave reviews!" Maki exclaimed. "Not knowing anything about telemedicine, when I first heard about it I thought it seemed like a way of cheating on care," he admitted. "But when I really looked at it, I realized that it was really improving the quality of care."

He also pointed out that, though it was not the goal, telemedicine is providing oversight by getting "another pair of eyes" on the medical conditions in DOC. He went on to say that since the implementation of telemedicine, reports have shown improvement in the delivery of meds to inmates and their adherence to their HIV regimens. He would love to see it expanded to serve inmates with other conditions besides HIV, especially since telemedicine enables the prisons to gain the benefit of experts in specific diseases at a fraction of the cost.

"It's really the best of both worlds," said Maki. "You're saving money while you're providing better care."

There is also exciting potential for telemedicine to provide some "infrastructure" that could be used by parole officers to better understand and monitor the medical needs of their parolees. Maki wishes that parole officers and soon-to-be parolees could meet well ahead of the release date in order to establish awareness of the inmate's medical and mental health needs, as well as providing a better foundation for this most important relationship between the inmate and law enforcement. "An inmate is going to live or die by their parole officer," says Maki, so the more the officer knows, the better the outcome for them both.

Maki says that JHA intends to use an upcoming grant to delve into the issue of telemedicine and medical conditions at DOC. Though there are obvious problems, he gave the DOC credit for doing some innovative things, such as their partnering with the AIDS Foundation of Chicago to produce and screen "Outside the Walls," a video educating inmates on HIV treatment and prevention and encouraging them to take charge of their health upon their release (see "Video Readies Inmates for Return to Society").

Hope for the Future

What would Maki ultimately like to see in terms of HIV and the DOC?

"I think the opt-out testing is a good start," he said. "But I'd like to see the DOC really seeing diagnosis and treatment education as part of its mission and that it's really instrumental to public health." He'd also like to see more emphasis on prevention, including condoms being provided.

To Maki, continuity of care is also crucial and that means from the point of entry, through the sentence, to the transition back to the community. He mentioned Sheridan Correctional Center and Southwestern Illinois Correctional Center, the so-called "drug treatment prisons," as places that focus on providing continuity of care. The fact that they focus on treating drug addiction and the other issues that often come with it gives them a somewhat different mindset than other prisons and it encourages a focus on continuity of care. Plus, the drug treatment facilities often have better resources than other facilities.

A man who likes a challenge, Maki admits to being "intrigued" by the "messiness" of the whole situation. He takes the DOC at their word when they say the testing program will be implemented in the spring. While it is just a first step in the right direction, in a system where things are so dysfunctional, he says, "Small victories mean a lot and even small changes can be really powerful."

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